08. Permission from physician to contact patient or patient’s family ? 

09. Permission from patient or patient’s family to recontact for followup ? 

SAMPLE EXTENDED DATA COLLECTION (Long Form) 

Case ID:_______________________ 

Reporting and Follow-up Information 

1. Date case was reported to the state health department _______/ _______/ ________ (mm/dd/yyyy) 

2. Date case report form initiated _______/ _______/ ________ (mm/dd/yyyy) 

3. Name of person completing form__________________________________________________________ 

4. Person reporting case to health department: 

Name and Position: ____________________________________________________________________________________________________________ 

Institution: ___________________________________________ Street address: ______________________________________________ 

City: _________________________________________________ State/Country: ________________________ Zip: __________________ 

Phone: ______________________________________________ Pager: _____________________________________________________ 

Fax: ______________________________________________ Email: ________________________________________________________ 

5. Other epi/medical contacts (include health departments, clinicians, laboratorians, medical records staff) 

Name and Position Contact numbers 

a. ___________________________________________________________ ___________________________________________________________ 

b. ___________________________________________________________ ___________________________________________________________ 

c. ___________________________________________________________ ___________________________________________________________ 

d. ___________________________________________________________ ___________________________________________________________ 

e. ___________________________________________________________ ___________________________________________________________ 

6. Facilities where patient received medical care for current illness 

Hospital/ Clinic Name Patient or Medical Record Admission/ Visit Date 

a. ___________________________________________________ _______________________________ _______/ _______/ ________ 

b. ___________________________________________________ _______________________________ _______/ _______/ ________ 

c. ___________________________________________________ _______________________________ _______/ _______/ ________ 

d. ___________________________________________________ _______________________________ _______/ _______/ ________ 

e. ___________________________________________________ _______________________________ _______/ _______/ ________ 

7. Patient and family contacts 

Name and Relationship to Patient Contact numbers 

a. ___________________________________________________________ ___________________________________________________________ 

b. ___________________________________________________________ ___________________________________________________________ 

c. ___________________________________________________________ ___________________________________________________________ 

d. ___________________________________________________________ ___________________________________________________________ 

e. ___________________________________________________________ ___________________________________________________________ 

Yes No 

10. Data sources used to complete form (Check all that apply) Physician interview Medical record review 

Patient/patient’s family 

11. Patient’s current status: Died Discharged to chronic care facility 

Yes No 

Hospitalized, in ICU Discharged home 

Hospitalized, on ward Never hospitalized 

12. Diagnoses: ____________________________________________________________________________________________ 

(1 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 
 

 

 

 

 

 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Demographic Information 

1. Patient Name First: ______________________________ Last: __________________________________________ 

2. Age: _______________ Years/ Months/ Days (Circle One) 

3. Date of birth: (mm/dd/yyyy) _______/ _______/ ________ 

4. Sex: Male Female 

5. Race: check one White 

Black/African American 

Asian 

Hawaiian/Pacific Islander 

American Indian/Native Alaskan 

Unknown 

Other, specify: _____________________________________ 

6. Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown 

7. Was the patient born in the United States? Yes No Unknown 

If NO, Country of birth: ___________________________________________________ Year emigrated to U.S. ___________ 

8. Place of residence:

Street address: __________________________________________________________________________________________ 

City: ___________________________________ State: ________________________ Zip: _____________________________ 

County: ___________________________________ Country: _____________________________________________________ 

Phone #: (_______) ________ - _______________ Phone2 #: (_______) ________ - ________________________________ 

9. Does patient live in an institutional setting? 

If YES, Name of facility: __________________________________________ Yes Unknown 

Room number: _____________ 

No 

Type of facility: Nursing home/long-term care facility Jail/prison 

Residential program/treatment facility Other: ____________________________ 

Shelter 

10. Date of illness onset: _______/ _______/ ________ (mm/dd/yyyy) 

11. Was the patient evaluated by a physician for this illness? Yes No Unknown

Yes Unknown 

Yes 

12. Was the patient evaluated at an emergency room for this illness? No

13. Was the patient hospitalized for this illness? No Unknown

If YES, Date first hospitalized _______/ _______/ ________ (mm/dd/yyyy) 

Yes Unknown 

If YES, Date discharged _______/ _______/ ________ (mm/dd/yyyy) 

14. If hospitalized, has the patient been discharged? No 

Occupation 

In the ONE MONTH PRIOR to illness onset (unless otherwise noted), did the patient: 

1. Work outside of the home? Yes No Unknown 

If YES, Occupation: _____________________________________________________________ 

Company name: _______________________________________________________________ 

Describe activities: _____________________________________________________________ 

If YES, In a healthcare setting (e.g doctor’s office, hospital, nursing home, lab)? Yes No Unknown 

2. Attend school or day care? Yes No Unknown 

If YES, Name of school or day care: _______________________________ 

3. Have children in day care? Yes No Unknown 

If YES, Name of school or day care: _____________________________ 

(2 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 
 

 

 

 

 ____________________________ ________________________ 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Exposures to Respiratory Illness 

In the ONE MONTH PRIOR to illness onset (unless otherwise noted), did/was the patient: 

1. Have contact with anyone with a respiratory illness? Yes No Unknown 

If YES, Type of contact (check all that apply): Household/Intimate Institutional setting 

Healthcare setting Other, specify: _________________________ 

Co-worker 

If YES, dates of exposure: First date: _______/ _______/ ________ Last date: _______/ _______/ ________ 

Yes Unknown 

If YES, Date admitted: _______/ _______/ ________ Date discharged: _______/ _______/ ________ 

Describe reason for hospitalization: _____________________________________ 

2. Admitted to the hospital for another illness/condition ? No 

1. Travel outside of the United States? Yes No Unknown 

If YES, List countries: ________________________________________________________________________ 

2. Travel within the U.S but outside of his/her home state? Yes No Unknown 

If YES, List states: ________________________________________________________________________ 

Recreational activities (within past 8 weeks) 

1. Garden, excavate or work with soil? Yes No Unknown 

2. Spent time in an infrequently used structure/space (e.g. attic or cabin)? Yes No Unknown 

3. Perform construction or renovations? Yes No Unknown 

4. Mow grass or hay? Yes No Unknown 

5. Go hiking or camping? Yes No Unknown 

6. Explore caves ? Yes No Unknown 

7. Have water exposures (e.g. fishing, boating, swimming, hot tub)? 

If YES, Type of water: Pool Saltwater (e.g. ocean) Freshwater (e.g. lake, river, stream) Other:___________________ 

Animal Exposures (within past 8 weeks) 

1. Have animals living in his/her home (including pets)? 10. Skin, dress, or eat wild game? 

Yes No Unknown Yes No Unknown

2. Receive an animal bite (including wild and 11. Spend time on a farm, rural area or petting zoo?

domestic animals)? Yes No Unknown Yes No Unknown

12. Perform or assist with an animal necropsy? 3. Receive an insect bite (e.g. mosquito, tick, spider)? Yes No Unknown

Yes No Unknown 13. Have close contact with animals in any other setting? 

4. Have close contact with rodents (e.g. rats, mice, 

squirrels, prairie dogs)? 

Yes Unknown 

Yes 

No 

No Unknown If the patient answered YES to any of the above questions, 

5. Have close contact with rodent droppings list animal(s)/insect(s), and type of exposure 

or rodent nests? Yes No Unknown Animal/Insect Type of exposure: 

6. Have close contact with birds (includes 

turkeys and chickens)? 

a. ____________________________ ________________________ 

Yes No Unknown b. ____________________________ ________________________ 

7. Have close contact with bird droppings? c. ____________________________ ________________________ 

Yes No Unknown d.

8. Have close contact with swine? Yes No Unknown

9. Go hunting or fishing? Yes No Unknown

(3 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 

 

 

___________________________________________________________________________________________________________________________ 

Travel History (within past 8 weeks)
 

 

 

 

 

 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Medications/Biologicals 

In the ONE MONTH PRIOR to illness onset (unless otherwise noted), did/was the patient: 

1. Receive any immunizations? Yes No Unknown 

If YES, List vaccines:________________________________________________________ 

2. Receive an influenza vaccine THIS SEASON? Yes No Unknown 

If yes, date of last vaccination: ____/____/_____ 

3. Take any medications including prescription, over the counter, or herbal remedies? Yes No Unknown 

If YES, List medications:________________________________________________________ 

Other exposures 

1. Smoke cigarettes? Yes No Unknown 

2. Work with any chemicals or toxins? Yes No Unknown 

If YES, Specify: 

3. Have any other significant exposures? Yes No Unknown 

If YES, Describe: 

Past Medical History 

Prior to his/her recent illness, had the patient ever been diagnosed with any of the following conditions: 

1. AIDS/HIV-positive? Yes No Unknown 

2. Any other immune compromising conditions/medications (e.g. steroids, chemotherapy)? Yes No Unknown 

If YES, Condition/Medication(s): ________________________________________________________ 

3. Bone marrow or solid organ transplant? Yes No Unknown 

4. Asplenia (no spleen)? Yes No Unknown 

5. Autoimmune disease, such as lupus? Yes No Unknown 

If YES, Type of disease: ___________________________________________________ 

6. Cancer/ malignancy? Yes No Unknown 

If YES, Type of cancer: ___________________________________________________ Year diagnosed: _____________ 

7. Indwelling catheter? Yes No Unknown 

8. Chronic lung disease? Yes No Unknown 

9. Asthma? Yes No Unknown 

10. Active tuberculosis or positive PPD? Yes No Unknown 

11. Heart disease? Yes No Unknown 

12. High blood pressure (hypertension)? Yes No Unknown 

13. Stroke? Yes No Unknown 

14. Deep venous thrombosis or coagulopathy? Yes No Unknown 

15. Sickle cell disease/thalassemia/hemoglobinopathy? Yes No Unknown 

16. Diabetes mellitus? Yes No Unknown 

17. Goiter or thyroid disease? Yes No Unknown 

18. Renal insufficiency or failure? Yes No Unknown 

If YES, On dialysis Yes No Unknown 

19. Chronic hepatitis or liver disease? Yes No Unknown 

20. Any other significant conditions? Yes No Unknown 

If YES, Specify: 

(4 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

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hysical signs

 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Review of Symptoms 

As part of this illness, has the patient had any of the following symptoms: 

1. Fever? Yes No Unknown 

2. Sweats? Yes No Unknown 

3. Chills/rigors? Yes No Unknown 

4. Cough? Yes No Unknown 

If YES, with sputum production? Yes No Unknown 

If YES, bloody sputum/ hemoptysis? Yes No Unknown 

5. Wheezing? Yes No Unknown 

6. Shortness of breath/difficulty breathing? Yes No Unknown 

7. Chest pain? Yes No Unknown 

8. Runny nose? Yes No Unknown 

9. Sore throat? Yes No Unknown 

10. Difficulty swallowing? Yes No Unknown 

11. Ear pain? Yes No Unknown 

12. Red or draining eyes? Yes No Unknown 

13. Muscle aches? Yes No Unknown 

14. Joint pain/swelling? Yes No Unknown 

15. Enlarged/swollen glands? Yes No Unknown 

16. Rash? Yes No Unknown 

17. Stiff neck? Yes No Unknown 

18. Seizures? Yes No Unknown 

19. Vomiting? Yes No Unknown 

If YES, with blood? Yes No Unknown 

20. Diarrhea? Yes No Unknown 

If YES, with blood? Yes No Unknown 

21. Dark or bloody urine? Yes No Unknown 

22. Yellow skin/eyes (jaundice)? Yes No Unknown 

23. Any other significant symptoms? Yes No Unknown 

If YES, Describe, including dates of onset: Yes No Unknown 

24. Date of symptom resolution: _______/ _______/ ________ 

Date first noted: (mm/dd/yyyy) 

(5 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 
_______________________ 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

 _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

______/ _______/ _______ 

 

 

 

 

 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:

Physical signs 

As part of this illness, did the patient have any of the following signs on physical exam? 

Date first noted: (mm/dd/yyyy) 

1. Recorded temperature >38.0 C (100.4 F) Unknown ______/ _______/ _______
 

If YES, max temperature recorded _________ _________ . _________ 

 ______/ _______/ _______
 

______/ _______/ _______
 

C or F (circle one)
 

First date max temperature was recorded

Last date patient had a fever >38.0 C 

Yes No 

2. Systolic blood pressure <90 mm Hg Yes No Unknown 

3. Room air oxygen saturation <95% Yes No Unknown

4. Wheezes or rhonchi Yes No Unknown

5. Rales or crackles Yes No Unknown

6. Signs of respiratory distress Yes No Unknown

7. Adult respiratory rate (RR) =>25 Yes No Unknown

(Child <5 years: RR > 40) Yes No Unknown

(Infant: RR > 50) Yes No Unknown

8. Arrhythmia Yes No Unknown

9. Lymphadenopathy Yes No Unknown

If YES, check all location(s): 

Postauricular 

Inguinal 

Axillary 

Submandibular 

Cervical Mediastinal 

10. Rash Yes No Unknown 

Macules/papules Vesicles/bullae Eschar If YES, check all types noted:

Morbilliform Ulcers/sores Erythroderma 

Petechiae/purpura Peeling/desquamation 

If YES, check all sites involved: Head/neck
 

Trunk
 

Extremities
 

11. Mucosal lesions Yes No Unknown 

12. Meningismus/ nuchal rigidity Yes No Unknown 

13. Seizures Yes No Unknown

14. Altered mental status of >24h duration Yes No Unknown

If YES, level of consciousness (check all that apply) Confused Lethargic 

Disoriented Agitated 

Drowsy Comatose 

15. Focal neurologic abnormality Yes No Unknown 

If YES, describe:____________________________________

16. Hepatosplenomegaly Yes No Unknown

17. Jaundice/icterus Yes No Unknown

18. Any other significant physical findings Yes No Unknown

If YES, Describe, including dates first noted:

(6 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention
 

 

 

 

 

 ______/ _______/ _______ 

 ______/ _______/ _______ 

_________________________ ___ 

 

 

_________________________ ___ 

 

 

_________________________ ___ 

 

 

_________________________ ___ 

 

 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Imaging studies 

At any point during this acute illness, did the patient receive any of the following imaging studies? 

1. Chest x-ray or CT scan: 

If YES, Date first performed: Overall impression:

If abnormal findings, check all that apply: Single lobar infiltrate 

Multi-lobar infiltrate 

Complete opacification

Interstitial infiltrate 

Yes No Unknown 

Pleural effusion 

Hilar adenopathy 

Granuloma 

Pneumothorax 

Normal

Pneumomediastium 

Widened mediastinum 

Pulmonary cavity or blebs 

Empyema 

Abnormal Unknown 

Enlarged heart 

Enlarged trachea 

Enlarged epiglottis 

Check all alveolar spaces with any abnormality: Left upper lobe 

Left lingula 

Left lower lobe 

Right upper lobe 

Right middle lobe 

Right lower lobe 

Summarize findings:_________________________________________________________________________________________________________________________ 

2. Another chest x-ray or CT scan with significantly different findings: Yes No Unknown 

If YES, Date performed: Overall impression: Normal Abnormal Unknown 

If abnormal findings, check all that apply: Single lobar infiltrate Pleural effusion Pneumomediastium Enlarged heart 

Multi-lobar infiltrate Hilar adenopathy Widened mediastinum Enlarged trachea 

Complete opacification Granuloma Pulmonary cavity or blebs Enlarged epiglottis 

Interstitial infiltrate Pneumothorax Empyema 

Check all alveolar spaces with any abnormality: Left upper lobe Left lower lobe Right middle lobe 

Left lingula Right upper lobe Right lower lobe 

Summarize findings:_________________________________________________________________________________________________________________________ 

Yes Unknown
 

If YES, Date performed: ______/ _______/ _______
 

Ejection fraction: __________ %
 

Overall impression:


3. Cardiac catheterization or echocardiogram: No 

Normal Unknown
 

Summarize findings:_________________________________________________________________________________________________________________________
 

Abnormal 

Yes Unknown


If YES, Type of imaging study:__________________
 

If YES, Date performed: ______/ _______/ _______
 

Site imaged:
 

4. Other imaging study: No 

Head Abdomen Other:__________________
 

Chest 
 Pelvis
 

Overall impression:
 Normal Unknown
 

Summarize findings:_________________________________________________________________________________________________________________________
 

Abnormal 

(7 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

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SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Hematology and Serum Chemistries 

For the following tests, please list the intial values and any additional values if results changed significantly: 

First recorded Other significant values 

Date 1: Date 2: Date 3: Date 4: 

____ /_____ / ______ ____ /_____ / ______ ____ /_____ / ______ ____ /_____ / ______ 

White blood cell count (WBC) ___________ cells/mm3 ___________ cells/mm3 ___________ cells/mm3 ___________ cells/mm3 

Differential for WBC above: 

Neutrophils: ___________ % ___________ % ___________ % ___________ % 

Bands: ___________ % ___________ % ___________ % ___________ % 

Lymphocytes: ___________ % ___________ % ___________ % ___________ % 

Eosinophils: ___________ % ___________ % ___________ % ___________ % 

Hematocrit (Hct) ___________ % ___________ % ___________ % ___________ % 

Platelets (Plt) ___________ 103/mm3 ___________ 103/mm3 ___________ 103/mm3 ___________ 103/mm3 

Prothrombin time (PT) ___________ sec ___________ sec ___________ sec ___________ sec 

INR ___________ ___________ ___________ ___________ 

Sodium (Na) ___________ mEq/L ___________ mEq/L ___________ mEq/L ___________ mEq/L 

Potassium (K) ___________ mEq/L ___________ mEq/L ___________ mEq/L ___________ mEq/L 

Chloride (Cl) ___________ mEq/L ___________ mEq/L ___________ mEq/L ___________ mEq/L 

Bicarbonate (HCO2) ___________ mEq/L ___________ mEq/L ___________ mEq/L ___________ mEq/L 

Calcium ___________ mEq/L ___________ mEq/L ___________ mEq/L ___________ mEq/L 

Creatinine ___________ mg/dL ___________ mg/dL ___________ mg/dL ___________ mg/dL 

Blood urea nitrogen (BUN) ___________ mg/dL ___________ mg/dL ___________ mg/dL ___________ mg/dL 

Glucose ___________ mg/dL ___________ mg/dL ___________ mg/dL ___________ mg/dL 

SGPT/ALT ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

SGOT/AST ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

Total bilirubin ___________ mg/dL ___________ mg/dL ___________ mg/dL ___________ mg/dL 

Serum ammonia ___________ mcg/dL ___________ mcg/dL ___________ mcg/dL ___________ mcg/dL 

Alkaline phosphatase ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

Lactate dehydrogenase (LDH) ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

Lipase ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

Creatine kinase (CK or CPK) ___________ U/L ___________ U/L ___________ U/L ___________ U/L 

C-Reactive protein (CRP) ___________ mg/dL ___________ mg/dL ___________ mg/dL ___________ mg/dL 

Erythrocyte sed rate (ESR) ___________ mm/hr ___________ mm/hr ___________ mm/hr ___________ mm/hr 

Albumin ___________ gl/dL ___________ gl/dL ___________ gl/dL ___________ gl/dL 

(8 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

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_______/ _______/ ________ 

______________________ ___ 

 

 

 

 

 

 

 

 

SAMPLE EXTENDED DATA COLLECTION 

Case ID:_______________________ 

Medications and Blood Products 

At any point during this acute illness, did the patient receive any of the following? 

1. Antimicrobials (include antibacterial, antiviral, and antifungal agents): Yes No Unknown 

2. Immune modulating, immune suppressive or anti-inflammatory agents (e.g steroids, Yes No Unknown 

azathioprine, methotrexate): 

3. Any other medications after symptom onset, including acetaminophen, ibuprofen or other 

over the counter medications: Yes No Unknown 

If YES to any of questions 1-3, please complete the following information for each agent received 

Name of the agent Date 1st received Date last received Route of administration 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

_________________________________ _____/ _______/ _______ _____/ _______/ _______ PO IV IM Other 

4. Blood products: 

If YES, Check types of products received: Whole blood Platelets 

Immunoglobulins/IVIG Cryoprecipitate 

Fresh frozen plasma Packed red blood cells (pRBCs) 

Date 1st received any blood product: _______/ _______/ ________ 

Severity and Outcomes of illness 

At any time during the current illness, did the patient require or have? 

1. Admission to intensive care unit: Yes Unknown 

If YES, Date admitted: _______/ _______/ ________ Date discharged (if applicable): _______/ _______/ ________ 

No 

Yes Unknown 

If YES, Date started: _______/ _______/ ________ Date stopped: _______/ _______/ ________ 

2. Supplemental oxygen: No

3. Vasopressor medications (e.g. dopamine, epinephrine): Yes Unknown

If YES, Date started: Date stopped: _______/ _______/ ________ 

No 

4. Mechanical ventilation: Yes Unknown 

If YES, Date started: _______/ _______/ ________ Date stopped: _______/ _______/ ________ 

No 

Yes Unknown 

If YES, Date: _______/ _______/ ________ 

5. Cardiopulmonary arrest: No

6. Did the patient die? Yes Unknown 

If YES, Date: _______/ _______/ _______ 

No 

7. If the patient died, was an autopsy performed? Yes Unknown 

If YES, Date: _______/ _______/ ________ 

No 

Summarize findings:____________________________________________________________________________________________________________________________ 

(9 of 13) SAMPLE EXTENDED DATA COLLECTION INSTRUMENT LONG FORM Updated: Jan 2008 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 
uids 

s were obtained, please note the following results 

e* Date collected Protein (mg/dl) Glucose RBCs WBCs Polys Lymphs 

(mg/dl) (cells/mm3) (cells/mm3) (%) (%) 

veolar lavage (BAL), cerebrospinal fluid (CSF), pericardial fluid, peritoneal fluid, pleural fluid, synovial fluid, urine 
s 

Date Culture type (Check one) Result (Check one) If positive: 

Bacterial Viral Fungal No growth Positive Organism 1 Organism 2 Organism 3 

bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate,pericardial fluid, peritoneal 

m,synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine 
sts for Infectious Diseases 

r infectious diseases were performed (e.g. antibody tests/serology, antigen detection, PCR, special stains) complete below: 

 Date Test performed Results Interpretation (circle one) Laboratory notes (if present) 

Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate Positive Negative Indeterminate 

bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), nasopharyngeal swab/aspirate, pericardial fluid, peritoneal fluid, pleural fluid, acute 

um, paired sera, sputum, synovial fluid, tissue (specify site), throat/oropharyngeal swab, stool or urine 
y 

Biopsy tissue? Abnormal findings? Findings Comments (Check all that apply) Comments 

Yes 

No 

Yes 

No 

Inflammation Edema Granuloma 

Hemorrhage Fibrosis Cirrhosis 

Necrosis Vasculitis Organisms present 

Biopsy tissue? Abnormal findings? Findings Comments (Check all that apply) Comments 

Yes 

No 

Yes 

No 

Inflammation Edema Granuloma 

Hemorrhage Fibrosis Cirrhosis 

Necrosis Vasculitis Organisms present 

Biopsy tissue? Abnormal findings? Findings Comments (Check all that apply) Comments 

Yes 

No 

Yes 

No 

Inflammation Edema Granuloma 

Hemorrhage Fibrosis Cirrhosis 

Necrosis Vasculitis Organisms present 

Biopsy tissue? Abnormal findings? Findings Comments (Check all that apply) Comments 

Yes 

No 

Yes 

No 

Inflammation Edema Granuloma 

Hemorrhage Fibrosis Cirrhosis 

Necrosis Vasculitis Organisms present 

Biopsy tissue? Abnormal findings? Findings Comments (Check all that apply) Comments 

Yes 

No 

Yes 

No 

Inflammation Edema Granuloma 

Hemorrhage Fibrosis Cirrhosis 

Necrosis Vasculitis Organisms present 

 Adrenal, bone marrow, brain, spinal cord, heart, kidney, liver, lung, lymph node, muscle, skin, spleen, etc